MEDICARE:

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy

General Provider Information

NPI Number	:	1508792441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:

Provider Business Mailing Address
First Line	:	11517 HIGHWAY 92 STE 110
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-4310
Country	:	US
Telephone Number	:	678-667-7469
Fax Number	:	470-970-5961

Provider Business Practice Location Address
First Line	:	11517 HIGHWAY 92 STE 110
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-4310
Country	:	US
Telephone Number	:	678-667-7469
Fax Number	:	470-970-5961

Authorized Official
Title or Position	:	CEO
Name	:	JOSHUA NGUYEN
Credential	:
Telephone Number	:	678-667-7469

Provider Enumeration Date	:	06/19/2026
Last Update Date	:	06/19/2026

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